Crossing the Boundary

Have you ever shared personal information about yourself with a patient or known of another nurse who got “too involved” with a patient? Did you get an uneasy feeling about it?

If you have ever been a patient, you know that feeling of vulnerability that comes from having to rely on others to diagnose and treat your health problems. Even if you are a health care professional, there is still an imbalance of power, skill, and knowledge. Patients – and nurses — want to connect on a human level, to personalize what can seem a very uncomfortable, impersonal situation. But sometimes the connection can go too far. Professional boundaries are what separates the misuse or even abuse of power from an appropriate, professional relationship.

Most nurse-patient interactions are ethical, legal, and therapeutic. The question here for our purposes is, what constitutes “over-involvement?” While there is no bright line, there are guidelines and resources to help nurses steer clear of situations that could lead to disciplinary action or even criminal charges. The National Council of State Boards of Nursing (NCSBN) has defined three types of boundary issues: boundary crossings, boundary violations, and sexual misconduct.

The NCSBN defines boundary crossings as “brief excursions across professional lines of behavior….” These can be unintentional, unplanned or chance interactions, or they may be carefully considered efforts to help a patient. An example of the first would be “My mother had the same problem as you and she did just fine after she did ‘xyz.’ You will too.” An example of an intentional crossing could be a nurse who survived childhood cancer talking with a child who has the same cancer about his feelings to help the child cope. Another example is when a terminally-ill patient finds comfort in crocheting a baby hat for the pregnant nurse caring for her. Accepting the gift is a boundary crossing, but the nurse recognizes that the patient feels useful even at the end of life. Boundary crossings are one-time occurrences. The nurse returns to accepted professional limits and avoids further crossings.

Boundary violations are more significant and may involve repeated sharing of personal information, keeping secrets between the patient and nurse, or even times when the patient takes care of the nurse. For example, the patient asks why the nurse seems so distracted and upset. The nurse tells the patient about leaving her abusive husband and having financial struggles. The patient arranges rent-free housing for six months and gives the nurse a substantial personal loan to get through the divorce. This is clearly outside the lines of a professional relationship and puts both patient and nurse in difficult positions whether or not they recognize it.

In contrast to boundary crossings, boundary violations are usually more serious, longer-lasting, and tend to put the needs of the nurse before the patient’s needs. There may be more significant problems below the surface for both and patient care can suffer to the point of malpractice. Nursing boards have suspended or revoked licenses for violations under the “unprofessional conduct” provision of the nurse practice act.

The third type of boundary breach is sexual misconduct which the NCSBN describes as “an extreme form of boundary violation and includes any behavior that is seductive, sexually demeaning, harassing or reasonably interpreted as sexual by the patient” (NCSBN, “A Nurse’s Guide to Professional Boundaries.”) At the very least, a nurse may be disciplined for sexual harassment. If the conduct is severe enough, the nurse can face arrest and prison time, civil suits, fines, penalties, and loss of licensure. In the last decade alone there have been several cases where nurses and other health care professionals sexually assaulted patients. Protect the patient, preserve the evidence, report the incident as soon as possible, and document facts carefully.

Remember these points about boundary challenges:

It is the nurse’s responsibility to set limits on behavior. Politely deflect repeated personal questions or interest in your personal matters.

If there is a boundary crossing, consider the intent and whether the crossing serves a therapeutic purpose. Is the crossing in the patient’s best interest?

Also consider the care setting (in-patient vs. out-patient), the patient’s needs, and the size of the community. Some boundary crossings in small or rural areas happen despite a nurse’s best efforts – you may be related to or know a patient and an alternate caregiver may not be available. It is still important to maintain a professional relationship in the care setting.

Try to avoid caring for patients with whom you have a business, professional, or personal relationship. If that is not possible, explain to the patient that you must, for the patient’s benefit, remain professional.

Be careful about personal relationships after the nurse-patient relationship is ended. Social and romantic relationships can be problematic, especially if the patient requires future care.

Even if a patient initiates sexual contact or consents to it, boards of nursing still consider the contact sexual misconduct. You can be disciplined and lose your license.

Know your facility and state’s reporting rules for boundary violations and sexual misconduct. Report the conduct to the appropriate supervisor or office as soon as possible and document carefully.

Most boundary issues are innocent and harmless. Be alert for potential violations and respond carefully and thoughtfully. And remember that sexual misconduct is never appropriate.

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BJ Strickland

Beth J. (“BJ”) Strickland is from Tennessee. She is an RN with Bachelor’s and Master’s degrees in nursing and a Master’s degree in history from Vanderbilt University. She is also a licensed attorney with her Juris Doctor degree from the University of Tennessee. She has practiced nursing since 1976 and has experience in clinical nursing, administration and teaching in several clinical areas. She has practiced law in state and federal courts in Tennessee since 1996 with an interest in healthcare risk management, employment law and medical malpractice. She retired from the U.S. Army in 2015 as a Lieutenant Colonel. This article is not legal advice. It is offered only as information about nursing topics of interest. If you have legal questions, please speak with a licensed attorney in your area. Neither the author or the website publisher are responsible for any actions a reader may take based on material in this article or on this website.